Inspection·February 1, 2024

F 0554 follows: Level of Harm - Minimal harm or potential for actual harm Policy: It is the policy of the facility to ensure that resident's right to self-administer medications is observed. A resident who requests to self-administer medications will be assessed to determine if resident is able to safely self-medicate. Residents Affected - Few Procedures: 1) The IDT will assign a staff to evaluate resident's ability to safely administer medication. A Self-Administration Evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after health teaching. 2) The resident may store the medication at bedside if there is a physician order to keep it at bedside. 5) The resident's ability to self-administer medication will be assessed regularly by the facility to coincide with the MDS assessment or any notable change in status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide personal privacy during provisions of Activities of Daily (ADL) care. Residents Affected - Some This applies to 4 of 6 residents (R40, R11, R22, and R7) reviewed for privacy in the sample of 20. The findings include: 1. On January 30, 2024, at 9:58 AM, V4 (Certified Nursing Assistant/CNA) assisted R40 with ADL care. V4 removed R40's clothes to render incontinence care. R40 was wet with urine and had a bowel movement. During the process of care, V4 went back and forth to the bathroom multiple times to change her gloves and perform hand hygiene, leaving R40 totally naked in bed. In addition, V4 did not close the window curtain and draw privacy curtain all throughout the care. Though R40's roommate was not in the bedroom, he could have come in anytime. 2. On January 30, 2024, at 10:42 AM, V4 (CNA) assisted R11 to the bathroom for toileting care. The bathroom was located by the entrance of the bedroom. V4 did not close the bedroom door or the bathroom door while R11 was using the toilet. R11's roommate (R40) was inside the bedroom, sitting in his wheelchair and propelling it. 3. On January 30, 2024, at 12:45 PM, V4 (CNA) rendered morning care and incontinence care to R22. V4 cleaned R22's peri-area, changed clothes, and emptied the catheter bag. However, V4 did not draw the window curtain and privacy curtain during provisions of care. R22's bed was by the window. There were houses across the parking lot, which was facing R22's window. 4. On January 30, 2024, at 1:48 PM, V6 (CNA) rendered incontinence care to R7 and changed R7's incontinence brief. R7's bed was positioned near the window about 2.5 feet away, and was on the same level as the window. V6 did not close the window curtain during care. There was a building with a window across the facility, which was facing R7's bedroom window. On January 31, 2024, at 1:19 PM, V2 (Director of Nursing/DON) stated, Staff should provide privacy when providing care like closing the door, drawing privacy curtain and window curtain; it doesn't matter which floor the bedroom was located at, the staff should close the window curtain. The staff should expose only body parts they're providing care to. Facility's Policy and Procedure for Privacy and Dignity with revised date of July 28, 2023, shows: Policy Statement: It is the facility's policy to ensure that resident's privacy and dignity is always respected by staff. Procedures: 1. During care that requires privacy such as incontinence care, the resident will be placed in bed and the privacy curtain will be drawn to provide full visual privacy. If the privacy curtain is not sufficient to provide full visual privacy, the combination of the privacy curtain and privacy screen will be used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R17's Minimum Data Sheet (MDS), dated [DATE], shows R17 requires substantial to maximum assistance for toileting and personal hygiene care. Residents Affected - Some On January 30, 2024, at 11:25 AM, V6 (Certified Nursing Assistant/CNA) rendered morning care to R17. V6 mixed liquid Dove soap to the water in the basin. V6 cleaned/wiped R17 with soap and water using a washcloth, then she immediately patted the skin with towel. She repeatedly did this process all over R17's body without rinsing the skin with water. 4. R7's MDS, dated [DATE], shows R7 is dependent on staff for toileting and personal hygiene care. On January 30, 2024, at 1:48 PM, V6 (CNA) rendered incontinence care to R7. V6 used a wet washcloth with soap and water, then she patted it dry, without rinsing R7's skin. The soap used for R7 has an instruction which shows, Apply to wash cloth or directly to skin. Massage into lather, rinse, and towel dry. On January 31, 2024, at 1:07 PM, V2 (Director of Nursing/DON) stated that when soap is applied to the resident's skin, the staff must rinse the resident's skin to get the soap residue off and prevent skin irritation. Facility policy titled ADL Care included as follows: ADL care is provided to each resident in the facility in accordance to the resident's comprehensive assessment and care plan in order to identify, evaluate, and intervene to, maintain, improve or prevent an avoidable decline in ADLs. 4. ADL nursing care is performed daily for the residents based on the comprehensive assessment, plan of care, physician orders as well as ADL documentation on various shifts. such care may include as appropriate, but is not limited to: h. Daily assistance in eating: grooming/hygiene . Based on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and oral care. This applies to 4 of 10 residents (R7, R14, R16, R17) reviewed for ADL (Activities of Daily Living) care in the sample of 20. The findings include: 1. R14's face sheet included diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, anxiety disorder, unspecified, altered mental status, hyperosmolality and hypernatremia, and history of falling. R14's quarterly MDS (Minimum Data Set), dated November 23, 2023, showed R14 is severely impaired in cognition, and required substantial/maximal assistance in oral care and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R14's care plan, initiated July 21, 2023, included R14 requires assistance with ADLs which included personal hygiene. Goal for the same included resident will be assisted with ADLs as needed through the review date of February 11, 2024. On January 29, 2024, at 12:59 PM, R14 was lying in bed, and noted to have both nostrils with visible long hair sticking out, which was crusted in a brownish substance. R14's lips were dry and peeling, and R14's teeth had coating of whitish substance. R14 stated, I feel like I have a dirty mouth. They don't do (clean) it. This was relayed to V4, CNA (Certified Nursing Assistant), who had come into the room. V4 stated \she just started the shift. V4 remarked, She (R14) has long nose hairs and looks like boogers in her nose. Her lips are real dry. 2. R16's face sheet included diagnoses of unspecified lack of coordination, nonexudative age-related macular degeneration, bilateral, advanced atrophic without subfoveal involvement, and spondylosis without myelopathy or radiculopathy, lumbosacral region. R16's quarterly MDS, dated [DATE], showed \R16 was moderately impaired in cognition and required partial moderate assistance in personal hygiene. R16's care plan, initiated October 18, 2023, showed \R16 had a actual ADL self care deficit related to impaired mobility and impaired vision .as evidenced by needing the substantial/maximum assistance to dependent assistance of one to two staff members to meet her ADL needs. Goal included to be assisted with the proper level of assistance to meet her ADL needs as needed through the review date of March 26, 2024. On January 29, 2024, at 12:59 PM, R16 was seated in the dining room and noted to have long jagged nails. R16's hands were trembling and stated, they are all jagged. Would it be alright if you ask them to cut it? This information was relayed to V9 (Restorative CNA). On January 31, at 01:06 PM, V2 (Director of Nursing) stated staff should assist with mouth care first thing in the morning and nails should be cut as they grow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that one resident's ace wraps to his legs were applied according to doctor's order. Residents Affected - Few This applies to 1 of 20 residents (R24) reviewed for quality of care in the sample of 20. The findings include: 1. R24's Physician order, dated November 16, 2023, shows the following: wraps to bilateral lower extremity (BLE) for compression in the morning for edema and remove per schedule. R24's Care plan documents R24 has potential impairment to skin integrity related to impaired mobility, incontinence, impaired circulation, impaired cognition, skin fragility related to age, psychotropic medication uses and diagnoses of Parkinson's, Chronic Kidney Disease, Congestive Heart Failure, Dementia, Anemia, Obesity, Peripheral Artery Disease, Venous insufficiency, and Hypertension. This Care Plan includes the following intervention dated June 15, 2023: wraps to bilateral lower extremity for compression. On January 29, 2024, at 11:23 AM, R24 was sitting in a wheelchair in his room and his legs were not wrapped. R24's bilateral lower legs were very deep red, with large scales of dry skin, and edematous. R24 stated they do not always wrap his legs or put moisturizer on them. R24 stated, I think they are short-handed. Lately, they do not do it every day. R24 stated he would like the staff to wrap his legs. On January 29, 2024, at 4:02 PM, R24 was in his room in wheelchair and his legs were not wrapped. On January 30, 2024, at 12:36 PM, R24 legs were not wrapped and in dining room. R24 stated, No one wrapped my legs or put any moisturizer on today or last night. R24 legs were red, scaly, and edematous. On January 30, at 3:55 PM, R24's TAR shows the following: wraps are scheduled to be applied at 9:00 and removed at 2100. On January 30, 2024, at 4:00 PM, R24 was sitting in a wheelchair, and had wraps on his legs. R24 stated he did ask the nurse, and she wrapped his legs about 2 hours ago. On January 31, 2024, at 11:46 AM, R24 was in his room in a wheelchair. R24's dressing looked like one from the day before, with wide opening at the foot, and red food on it. R24 stated it is the same dressing from yesterday, and they did not remove the dressing at bedtime. On January 31, 2024 at 11:48 AM, V14 (Licensed Practical Nurse) stated R24 legs were wrapped when she came in this morning, and she did not change it today. V14 stated the night shift is supposed to take the dressing off at night, and the day shift should put it on in the morning. On January 31, 2024 at 2:33 PM, V2 (Director of Nursing) stated she expects staff to follow doctor's orders and wrap resident's legs and remove leg wraps if ordered also. As of 3:39 PM on January 31, 2024, there was no care plan for R24 that documented R24 refuses or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 resists care to have his wraps applied to his legs. Level of Harm - Minimal harm or potential for actual harm There was no progress note of R24 refusing to wear his ACE wraps on January 29, 2024, or January 30, 2024. Residents Affected - Few On February 1, 2024 at 12:16 PM, V2 stated the nurses should document on the resident's Treatment Administration Record (TAR) or nurses notes that R24 is refusing to wear his ace wrap. The facility's Physician Orders policy, dated July 8, 2023, shows the following. The facility shall ensure to follow physician orders as it is written in the Physician Order Summary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review, the facility failed to ensure the indwelling urinary catheter tube was secured to the resident to prevent potential tugging or pulling. Residents Affected - Few This applies to 3 of 4 residents (R7, R22, and R57) reviewed for urinary catheter care in the sample of 20. The findings include: 1. On January 30, 2024, at 12:45 PM, V4 (Certified Nursing Assistant/CNA) emptied R22's urinary catheter bag with 750 ml output. V4 proceeded to render peri-care. During the provisions of care, it was noted R22's urinary catheter tube was not secured to R22. It was moving freely and unsecured from side to side and was in between her buttocks while being repositioned. 2. On January 30, 2024, at 1:22 PM, V5 (CNA) rendered incontinence care to R57. During provisions of care, it was observed R57's urinary catheter was not anchored to R57. The urinary catheter tube was pulling during incontinence care and repositioning. 3. On January 30, 2024, at 1:48 PM, V6 (CNA) rendered incontinence care to R7, who had indwelling urinary catheter. The catheter tube was not anchored to R7. There was redness on R7's penis, and he was complaining of pain. When V6 was providing peri-care, R7 was complaining of pain with every movement of the unsecured catheter tube. On January 31, 2024, at 1:08 PM, V2 (Director of Nursing/DON) stated the catheter tube should be anchored to the resident to prevent pulling and tugging which could potentially cause injury. Facility's Urinary Catheter Care Policy and Procedure with revised date of July 28, 2023, shows: Changing Catheters: 2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R58's Physician order, dated August 15, 2023, shows: Enteral feed order every shift Jevity 1.5 enteral formula as bolus feeding as follows: 360 mL at 8:00 AM, 12:00 PM and 5:00 PM, and 240 mL at 9:00 PM. R58's tube feeding care plan, dated July 6, 2021, shows the following: R58 needs the Head of Bed elevated to 45 degrees during and thirty minutes after tube feed. R58's ADL (Activities of Daily Living) self-care plan shows R58 requires extensive assistance of 2 staff member for bed mobility. On January 29, 2024, at 11:08 AM, R58's bed was flat (completely parallel to the floor). The head of the bed was flat with no elevation. R58 was lying flat with one pillow under her head. V3 (Licensed Practical Nurse) flushed and started R58's tube feeding while resident was lying flat, then V3 left the room and R58 was still lying flat in the bed. V3 did not elevate R58's head-of-bed (HOB) before she left R58's room. R58 remained flat throughout the entire encounter. On January 29 2024, at 11:53 AM, R58 was still lying flat in her bed and the HOB was not elevated. R58's feeding was infusing, and there was about 150 mL (milliliters) left in the bag. On January 29, 2024, at 12:06 PM, R58's mother was in the room and the tube feeding was still infusing. There was about 100 milliliters of feeding left in the feeding bag, and R58 was still lying flat on her left side. R58's HOB was not elevated. On January 31, 2024 at 2:33 PM, V2 (Director of Nursing) stated a resident's head of bed should be elevated at a 45 degree angle when receiving tube feedings. V2 stated resident's beds should not be flat when feedings are being administered. V2 stated the bed should be raised to a 45 degree angle during feeding and for a few minutes after the feeding as a good practice. The facility's Enteral Tube Feeding Care policy dated July 28, 2023, shows the following: Procedure: 4. Check for placement of G tube (Gastrostomy Tube) prior to administration of an enteral formula, by checking if the G tube marking is still at the G tube insertion site. If the G tube marking cannot be found or the marking is too faint to see, the nurse will aspirate gastric content and check the ph of the aspirated material [to see] if it is between 1.5 to 5.5, which will confirm proper placement of the G tube in the stomach. 5. Flush the enteral tube with 15 to 30 CC (Cubic Centimeter) of water before starting the enteral feeding and after stopping the enteral feeding to ensure that the enteral formula in the enteral tubing is pushed to the stomach. 9. Residents on enteral feeding must be positioned in fowler's position at all times while the feeding is running. Based on observation, interview, and record review, the facility failed to check placement and flush a gastrostomy tube prior to enteral feeding, and to position a resident in fowler's position during enteral feeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 This applies to 2 of 5 residents (R80 and R58) reviewed for tube feeding in the sample of 20. Level of Harm - Minimal harm or potential for actual harm The findings include: Residents Affected - Few 1. The EMR (Electronic Medical Record) showed R80 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, stroke, dysphagia, and gastrostomy status. R80's MDS (Minimum Data Set), dated November 23, 2023, showed R80 had a feeding tube. R80's enteral feeding care plan, dated August 29, 2023, showed, [R80] requires enteral feedings as the primary source of nutrition, due to the following conditions and risk factors: dysphagia. The care plan continued to show multiple interventions dated August 29, 2023, including Monitor for complications: aspiration, diarrhea, respiratory infection, dehydration, abdominal pain, feeding tube displacement, nausea/vomiting, and abnormal lab values. On January 31, 2024, at 11:27 AM, V13 (RN/Registered Nurse) administered R80's enteral bolus feeding. V13 connected R80's enteral bolus feeding to R80's gastrostomy tube and infused the enteral feeding. V13 did not check placement of R80's gastrostomy tube or flush R80's gastrostomy tube with water prior to administering R80's enteral bolus feeding. On January 31, 2024, at 1:44 PM, V13 said she only checks placement of residents' gastrostomy tubes at the beginning of V13's shift, and does not check placement again throughout the shift. V13 continued to say she did not flush R80's gastrostomy tube prior to administering the enteral feeding. On January 31, 2024, at 2:26 PM, V2 (DON/Director of Nursing) said facility staff should check gastrostomy tube placement prior to every administration of enteral feeding because the gastrostomy tube can move at any time. V2 continued to say a resident's gastrostomy tube should be flushed with water before the enteral feeding is administered. V2 said V13 should have checked R80's gastrostomy tube placement and flushed R80's gastrostomy tube before administering the enteral feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications as ordered. There were 25 opportunities and 2 errors, resulting in an 8% medication error rate. Residents Affected - Few This applies to 1 of 5 (R30) residents reviewed for medication administration in the sample of 20. The findings include: The EMR (Electronic Medical Record) showed R30 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, myocardial infarction, schizophrenia, unspecified and bipolar disorder. R30's order summary showed Fexofenadine HCL (Hydrochloride) 180 mg (milligrams), one time a day, order initiated on January 3, 2024, for allergy and Gabapentin 100 mg give 200 mg three times a day at 9:00 AM, 2:00 PM, and 6:00 PM for epilepsy, order initiated on January 3, 2024. On January 29, at 12:26 PM, V10 (RN/Registered Nurse) was preparing to administer R30's medication scheduled for 9:00 AM. V10 stated Gabapentin 100 mg tablets and Fexofenadine HCL 180 mg were not available to be administered, they were not in the medication cart, and needed to be ordered from pharmacy. Neither medication was observed in the medication cup as V10 gave R30 her medication. R30's January 2024 MAR (Medication Administration Record), showed on January 29, 2024, 9:00 AM dose of Fexofenadine HCL 180 mg. and Gabapentin 200 mg. were not administered. On January 31, 2024, at 1:07 PM, V2 (DON/Director of Nursing) stated if a medication is not available to be administered as ordered, the nurse should notify the pharmacy, let the prescriber know if the medication is not administered as ordered, and possibly obtain the medication from the in-house pharmacy stock supply. The Facility's policy titled Medication Policy, dated July 28, 2023, showed, It is the policy of the facility to adhere to all Federal and State Regulations with medication pass procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy for Enhanced Barrier Precautions. The facility also failed to follow their policy for hand hygiene and glove use during provisions of care. Residents Affected - Some This applies to 6 of 20 residents (R7, R17, R22, R44, R58, and R80) in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R80 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure, stroke, dysphagia, and gastrostomy status. R80's MDS (Minimum Data Set), dated November 23, 2023, showed R80 had a feeding tube. R80's Order Summary Report, dated January 31, 2024, showed the following order dated September 30, 2023, Isolation Reason: Enhanced Barrier Precautions related to g-tube (gastrostomy tube) and trach (tracheostomy). On January 31, 2024, at 11:27 AM, V13 (RN/Registered Nurse) entered R80's room. R80's door had a sign posted titled Enhanced Barrier Precautions. V13 did not perform hand hygiene upon entering R80's room. V13 donned gloves and administered R80's enteral feeding. V13 did not wear an isolation gown. On January 31, 2024, at 2:26 PM, V2 (DON/Director of Nursing) said R80 was on Enhanced Barrier Precautions because R80 has a gastrostomy tube. V2 continued to say V13 should have performed hand hygiene upon entering R80's room and also worn a gown when administering R80's enteral feeding. 5. On January 29, 2024, at 10:52 AM, V3 (LPN/Licensed Practical Nurse) entered R44 and R58's room. R44 and R58 were roommates. There was an Enhanced Barrier Precautions (EBP) sign posted on the door outside of R44 and R58's room that showed gown and gloves should be worn when using tube feeding device, and when providing care to the tube feeding devise. There were isolation gowns outside of R44's room. V3 put on gloves and went into R44's room with two bottles of tube feeding and put it on the end table. V3 did not don a gown. V3 listened to R44 bowel sounds and went out of the room looking into the drawers of the medication cart and said she can't find acetaminophen liquid, and she will come back with that. V3 did not remove her gloves before going out of the room, and did not sanitize her hands before coming back into the room. V3 took R44's 60 cc (cubic centimeter) syringe that was hanging on the IV (Intravenous) Pole. V3 then went into the bathroom and filled a 60 cc syringe with water. V3 flushed the full 60 cc syringe. Water started spilling out of the tube and onto V3's gloves and on R44's stomach and bed. V3 went into the bathroom removed her gloves and got some paper towels. V3 put on new gloves, and did not sanitize her hand or wash her hands before coming out of the bathroom. V3 took and filled the feeding bag with 1.5 bottles of enteral feeding up to 400 milliliters (mL). V3 primed R44's tubing with the tube feeding and attached it while clear liquid was still coming out of the tubing. V3 took off her gloves after examining the g-tube (gastrostomy tube). and looked like she was getting ready to leave the bedside. Then V3 continued to examine the g-tube and didn't sanitize her hands. V3 was touching the tubing without any gloves on. V3 looked like she was trying to check patency while turning the knobs on the g-tube and touching enteral feeding bag. V3 grabbed the half bottle of enteral feeding and took it to her medication cart outside the room. V3 did not sanitize her hands after removing her gloves. V3 began touching the computer mouse and looking (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 up R58's (roommate's) medical record. Level of Harm - Minimal harm or potential for actual harm Then V3 took out R58 enteral feeding from the medication cart, locked cart, got gloves, and went into the room and did not sanitize her hands on the way in. V3 put gloves on and listened to bowel sounds around navel/insertion site. V3 later left the room and on the way back into the room V3 did not perform hand hygiene was not wearing any gloves or gown. V3 went into the bathroom and put water in the 60 cc syringe and got some paper towels and went out of the room to check the computer and did not sanitize her hands on the way back into the room. V3 put the paper towels down and put on gloves and pushed 60 cc of water into R58's tubing. Clear liquid flowed out of the R58's tubing. V3 primed tubing and connected the tubing. Clear liquid started coming out of the tubing and she cleaned with paper towels. V3 moved the garbage can with her gloved hands. V3 then removed her gloves and did not perform hand hygiene. V3 went to the restroom with the syringe poured some fluid into the sink and brought the syringe back to the bedside and hung it on the IV pole. V3 then went to her medication cart without performing hand hygiene. V3 started opening drawers and touching the cart. V3 did not put on a gown during any part of the encounters with R44 or R58. Residents Affected - Some On January 31, 2024 at 2:33 PM, V2 (Director of Nursing) stated staff in the EBP rooms should wear gloves and a gown and possibly goggles or shield. V2 stated staff should perform hand hygiene in and out of the room. V2 stated nurses should wash hands after handling a residents G-tube especially if hands are soiled and after removing gloves. The facility's Enhanced Barrier Precautions signs that are posted outside of residents' rooms read as follows: Enhanced Barrier Precautions (EBP): EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, and Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. The facility's Enhanced Barrier Precautions policy, dated October 23, 2023, shows the following: 3. The EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of XDROs (Novel or targeted multiple drug resistant organism) to staff hands and clothing. Use of eye protection may be necessary when splash or spray may occur. Examples of high-contact resident care activities require gown and glove use among residents that trigger EBP use include: a) Dressing, b) Bathing/Showering, c) Transferring, d) Providing hygiene, e) Changing Linens, f) Changing briefs or assisting with toileting, g) Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and h) Wound Care: any skin opening requiring a dressing. The facility's Hand Hygiene policy, dated July 28, 2023, shows the following: Policy Statement: Hand hygiene is important in controlling infections. Hand hygiene consist of either hand washing or the use of alcohol gel. The facility will comply with the CDC Guidelines in regards to hand hygiene. Procedures: Hand Hygiene using alcohol-based hand rub is recommended during the following situations: a. Before and after direct resident contact. g. Before moving from work on soiled body site to a clean body site on the same resident. h. After contact with blood, body fluids or surfaces contaminated with blood and body fluids. i. After removing gloves including during wound dressing change. 2. On January 30, 2024, at 11:25 AM, V6 (Certified Nursing Assistant/CNA) rendered morning care, which include incontinence care to R17, who was wet with urine and had a bowel movement. V6 used wet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm wash cloth with soap and water to clean R17. As V6 was cleaning R17's peri-area, V6's gloved hands touched the fecal matter. V6 went back and forth to the basin to wet the washcloth with soap and water, opened the bedside vanity door to get the wet wipes to use for R17's perineum, placed a clean incontinence brief and clean incontinence pad under R17, and applied barrier cream to R17's back perineum, while wearing the same soiled gloves. Residents Affected - Some 3. On January 30, 2024, at 12:45 PM, V4 (CNA) rendered morning which include incontinence care to R22. V4 cleaned R22's perineum from front to back and applied barrier cream with the same soiled gloves. After V4 applied the barrier cream, she changed her gloves, without hand hygiene, and completed the care by placing new incontinence brief, assisted R22 to reposition. 4. On January 30, 2024, at 1:48 PM, V6 (CNA) rendered incontinence care to R7. V6 cleaned peri-area, removed soiled incontinence brief, straightened clean linen/bedding, placed pillow under R7's head, and helped reposition R7, while wearing the same soiled gloves. On January 31,2024, at 1:12 PM, V2 (Director of Nursing/DON) stated staff should perform hand hygiene prior to care and change gloves and perform hand hygiene from dirty to clean task to prevent spread of infection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were offered pneumococcal vaccination in accordance with their policy and CDC (Center for Disease Control) guidelines. Residents Affected - Some This applies to 5 of 9 residents (R7, R26, R29, R32, and R46) reviewed for immunizations in the sample of 20. The findings include: 1. The EMR (Electronic Medical Record) showed R7 was [AGE] years old. R7 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, diabetes type 2, and hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non dominant side. R7's immunization record showed R7 had not been offered nor received any pneumococcal vaccine since admission, prior to January 13, 2024. R7 had consented to receive the vaccine on January 13, 2024, but as of January 31, 2024, had not received the vaccine. On January 31, 2024, at 1:40 PM, V12 (Infection Preventionist) stated there is no documentation to show R7 had previously been offered the pneumococcal vaccine prior to January 13, 2024. V12 also stated the facility can obtain the pneumococcal vaccine from the pharmacy and administer the vaccine within the facility. V12 further stated R7 was eligible to receive the pneumococcal vaccine according to the CDC policy and facility policy at the time of admission. 2. The EMR showed R26 was [AGE] years old. The EMR showed R26 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, atherosclerotic heart disease, essential hypertension, and unspecified dementia without behavioral disturbance. R26's immunization record showed R26 had not been offered the pneumococcal vaccine since admission until January 11, 2024, when R26 consented to receive the vaccine. The facility does not have documentation to show R26 has been administered the pneumococcal vaccine. On January 31, 2024, at 1:41 PM, V12 stated there is no documentation to show R26 had been offered the vaccination previously, and stated R26 would have been eligible to receive the pneumococcal vaccine at the time of admission. 3. The EMR showed R29's was age [AGE] years old. The EMR showed R29 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease, combined systolic and diastolic congestive heart disease, atherosclerosis artery disease of both the right and left legs with ulceration, osteoarthritis unspecified and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. R29's state immunization record showed R29 had received the Prevnar 13 pneumococcal vaccine on September 9, 2015, prior to admission. R29's EMR did not contain the Prevnar 13 administration data. R29 consented to pneumococcal vaccine on January 10, 2024, and the vaccine had not been administered as of January 31, 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terra Lagrange 4735 Willow Springs Road LA Grange, IL 60525 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On January 31, 2024, at 1:38 PM, V12 stated R29 should have been offered the pneumococcal vaccine, either the PCV20 or PPSV23 in accordance with the facility policy at the time of admission. V12 stated there is no record that showed R29 had been offered the pneumococcal vaccine prior to January 10, 2024. 4. The EMR showed R32 was [AGE] years old. The EMR showed R32 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes, peripheral vascular disease, chronic kidney disease stage 4, morbid obesity severe due to excess calories, paroxysmal atrial fibrillation and neuromuscular dysfunction of the bladder. R32's immunization record showed R32 has not been offered the pneumococcal vaccine since admission and has not received the vaccine, prior to January 31, 2024. R32 signed a consent to receive the pneumococcal vaccine on January 31, 2024. On January 31, 2024, at 1:36 PM, V12 stated R32 would have been eligible to receive the pneumococcal vaccine at the time of admission. V12 stated there is no documentation to show that R32 had been offered the pneumococcal vaccine since admission. 5. The EMR showed R46 was [AGE] years old. The EMR showed R46 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, unspecified, venous insufficiency with peripheral vascular disease, muscle wasting, and atrophy not elsewhere classified, multiple sites, and pressure ulcers of the right and left heels. R46's state immunization record showed R46 received Prevnar13 vaccine on March 15, 2018, prior to admission. This vaccine was not documented as administered in R46's immunization tab in the medical record. R46 signed a consent to receive the pneumococcal vaccine on January 11, 2024, and as of January 31, 2024, the vaccine has not been administered. On January 31, 2024, at 1:30 PM, V12 stated R46 was eligible to be offered the pneumococcal vaccine, either PCV20 or PPSV23 in accordance with the facility's policy at the time of admission. There was no documentation that showed R46 was previously offered the pneumococcal vaccine from the time of admission until January 11, 2024. On January 31, 2024, at 1:30 PM, V12 stated at the time of admission, all residents' immunizations should be reviewed to determine the need for pneumococcal vaccine. V12 further stated there is a website from the state to view any previous vaccine administration, and that website lists data that can be added to the resident's immunization tab in their medical record as historical data, in order to have a complete immunization record. V12 stated the facility uses an outside vendor to hold vaccine clinics, but there is currently no date for a pneumococcal vaccine clinic. V12 also stated the facility can obtain the vaccine from the pharmacy and administer the vaccine in the facility. The facility policy titled Pneumococcal Vaccination, dated October 5, 2016, and revised December 12, 2023, showed, It is the policy of the facility to offer and administer pneumococcal vaccinations to each resident as recommended by the CDC's ACIP (Advisory Committee on Immunization Practices) unless otherwise contraindicated or the resident or responsible party has refused the vaccine. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145737 If continuation sheet Page 16 of 16